HOW TO TREAT DEPRESSIVE EPISODE 2025

HOW TO TREAT DEPRESSIVE EPISODE 2025

GUIDELINES FOR THE DIAGNOSIS AND TREATMENT OF COMMON MENTAL DISORDERS

(Enacted under Decision No. 2058/QĐ-BYT dated May 14, 2020, by the Minister of Health)

Article 20

DEPRESSIVE EPISODE

CHIEF EDITOR

Associate Professor, PhD Nguyễn Trường Sơn

CO-EDITOR

Associate Professor, PhD Lương Ngọc Khuê

PhD Nguyễn Doãn Phương

CONTRIBUTING AUTHORS

PhD Trần Thị Hà An

MSc Trịnh Thị Vân Anh

PhD Vũ Thy Cầm

MSc Trần Mạnh Cường

PhD Nguyễn Văn Dũng

PhD Vương Ánh Dương

PhD Lê Thị Thu Hà

MSc Trần Thị Thu Hà

MSc Phạm Công Huân

MSc Đoàn Thị Huệ

Specialist Doctor II Nguyễn Thị Minh Hương

MSc Vũ Thị Lan

1. Nguyễn Phương Linh

Specialist Doctor II Nguyễn Thị Phương Loan

MSc Bùi Văn Lợi

MSc Nguyễn Thị Phương Mai

PhD Trần Nguyễn Ngọc

MSc Bùi Nguyễn Hồng Bảo Ngọc

MSc Trương Lê Vân Ngọc

MSc Bùi Văn San

PhD Dương Minh Tâm

MSc Phạm Xuân Thắng

MSc Lê Thị Phương Thảo

MSc Lê Công Thiện

MSc Vương Đình Thủy

Associate Professor, PhD Nguyễn Văn Tuấn

Specialist Doctor II Ngô Văn Tuất

MSc Đặng Thanh Tùng

MSc Vũ Sơn Tùng

MSc Cao Thị Ánh Tuyết

MSc Nguyễn Thị Ái Vân

Specialist Doctor II Hồ Thu Yến

MSc Nguyễn Hoàng Yến

CONTRIBUTORS TO EVALUATION AND FEEDBACK

Associate Professor, PhD Nguyễn Thanh Bình

PhD Vũ Thy Cầm

PhD Nguyễn Hữu Chiến

Specialist Doctor II Võ Thành Đông

PhD Lê Thị Thu Hà

Specialist Doctor II Đỗ Huy Hùng

PhD Nguyễn Mạnh Hùng

MSc Nguyễn Trọng Khoa

Specialist Doctor II Ngô Hùng Lâm

Associate Professor, PhD Phạm Văn Mạnh

Specialist Doctor II Trần Ngọc Nhân

PhD Dương Minh Tâm

MSc Đặng Duy Thanh

PhD Vương Văn Tịnh

Specialist Doctor II Lâm Tứ Trung

PhD Lại Đức Trường

PhD Cao Văn Tuân

Associate Professor, PhD Nguyễn Văn Tuấn

SECRETARIAT TEAM

MSc Đặng Thanh Tùng

MSc Trương Lê Vân Ngọc

BA Đỗ Thị Thư

Article 20

DEPRESSIVE EPISODE

I. DEFINITION  

Depression is a pathological emotional state marked by an inhibition of overall mental activity. According to the ICD-10, a typical depressive episode is characterized by a persistent low mood, loss of interest or pleasure, and reduced energy leading to increased fatigue and diminished activity, lasting at least 2 weeks. Additional symptoms include impaired concentration, reduced self-esteem and confidence, feelings of guilt or worthlessness, a bleak and pessimistic view of the future, thoughts or acts of self-harm or suicide, sleep disturbances, and changes in appetite.

II. ETIOLOGY  

Depression arises from multiple causes, broadly categorized into three main types:  

– Endogenous Depression: Internally driven, often linked to biological factors.  

– Psychogenic Depression: Triggered by psychological stressors or life events.  

– Organic Depression: Resulting from physical conditions or substances affecting brain function.

III. DIAGNOSIS  

1. Definitive Diagnosis (ICD-10)  

1.1. Clinical Features  

– Core Symptoms (3):  

1. Persistent low mood, minimally varying day-to-day, often unresponsive to circumstances, lasting at least 2 weeks.  
2. Loss of interest or pleasure in activities.  
3. Reduced energy and increased fatigue.  

– Common Symptoms (7):  

1. Reduced concentration and attention.  
2. Low self-esteem, lack of confidence, and difficulty making decisions.  
3. Feelings of guilt or worthlessness.  
4. Pessimistic, bleak outlook on the future.  
5. Thoughts or acts of self-harm or suicide.  
6. Sleep disturbances.  
7. Appetite changes (increase or decrease) with corresponding weight changes.  

– Somatic/Biological Symptoms (8):  

1. Loss of pleasure in typically enjoyable activities.  
2. Lack of emotional reactivity to positive events or environments.  
3. Waking 2+ hours earlier than usual.  
4. Worse mood in the morning.  
5. Objective psychomotor retardation or agitation (noted by others).  
6. Reduced appetite.  
7. Weight loss (5% or more of body weight in the past month).  
8. Marked loss of libido.  

– Psychotic Symptoms: May or may not be present (e.g., delusions, hallucinations).  

Diagnostic Criteria:  

– First occurrence of characteristic clinical, common, and somatic symptoms of depression.  

– Episode lasts at least 2 weeks.  

– No history of meeting criteria for hypomania or mania (F30) at any point.  

– Not attributable to psychoactive substance use (F10-F19) or organic disorders (F00-F09).  

Subtypes:  

– Mild Depressive Episode (F32.0):  

  – 2/3 core symptoms + 2/7 common symptoms.  

  – F32.00: No/few somatic symptoms.  

  – F32.01: 4+ somatic symptoms (or 2-3 severe ones).  

– Moderate Depressive Episode (F32.1):  

  – At least 2/3 core symptoms + 3-4 common symptoms.  

  – Significant difficulty in social, occupational, or domestic functioning.  

  – F32.10: Few somatic symptoms.  

  – F32.11: 4+ somatic symptoms.  

– Severe Depressive Episode Without Psychotic Symptoms (F32.2):  

  – All 3 core symptoms + 4+ common symptoms, some markedly severe.  

  – Severe psychomotor symptoms may limit detailed symptom reporting, but classification as severe remains valid.  

– Severe Depressive Episode With Psychotic Symptoms (F32.3):  

  – Meets F32.2 criteria + delusions, hallucinations, or depressive stupor.  

  – Delusions often involve guilt, worthlessness, or impending doom; hallucinations may include accusing voices or smells of rot.  

  – Psychotic features may be mood-congruent or incongruent.  

– Other Depressive Episodes (F32.8):  

  – Atypical depression or single, unspecified depressive episodes not fitting F32.0-F32.3 but clinically depressive.  

1.2. Ancillary Testing  

– Basic Labs:  

  – Blood: Hematology, biochemistry, microbiology (HIV, HBV, HCV).  

  – Thyroid hormone levels.  

– Imaging/Functional Tests:  

  – Chest X-ray, abdominal ultrasound, transcranial Doppler, thyroid ultrasound.  

  – EEG, ECG, cerebral blood flow, polysomnography, CT/MRI brain (select cases).  

– Psychological Assessments:  

  – Depression scales: Beck, Hamilton, GDS, PHQ-9.  

  – Personality: MMPI, EPI.  

  – Pittsburgh Sleep Quality Index (PSQI).  

  – Anxiety scales: Zung, Hamilton, DASS.  

– Monitoring Tests:  

  – Metabolic effects: Blood glucose, lipids (cholesterol, triglycerides, LDL, HDL) every 3 months.  

  – Leukopenia: Complete blood count monthly.  

  – Liver, kidney function, ECG every 3 months.

2. Differential Diagnosis  

– Medical Conditions: Hypothyroidism (fatigue, sleep/appetite disturbances; confirmed by thyroid hormone tests).  

– Psychiatric Disorders: Adjustment disorder with depressed mood, somatic symptom disorder, mixed anxiety-depressive disorder.

IV. TREATMENT  

1. Treatment Principles  

– Goals:  

  – Address underlying causes (if identified).  

  – Reduce and eliminate symptoms.  

  – Prevent relapse and recurrence.  

– Process:  

  – Accurate diagnosis, assess severity and suicide risk, select appropriate antidepressants, ensure therapeutic dosing, monitor tolerability and adherence, maintain treatment post-symptom resolution.  

  – Acute phase: 2-4 months to resolve symptoms.  

  – Maintenance phase: 4-6 months to prevent relapse.  

  – Prophylactic phase: Varies, typically 1+ year, depending on patient and condition.  

– Adjunctive Treatments: Combine antidepressants with anxiolytics, antipsychotics, mood stabilizers, ECT, or psychotherapy as needed.

2. Treatment Framework  

2.1. Pharmacotherapy  

– Antidepressants: Adjust neurotransmitter activity (serotonin, norepinephrine). Effect onset: 7-10 days at therapeutic dose. Non-response to one may not preclude response to another.  

  – Traditional: MAOIs (rarely used due to drug interactions); TCAs (anticholinergic effects, inpatient use with monitoring).  

  – Newer Agents: Fewer side effects, faster onset, safer in overdose, minimal interactions.  

    – SSRIs: Sertraline, Fluoxetine, Fluvoxamine, Citalopram, Escitalopram, Paroxetine.  

    – SNRIs: Venlafaxine, Duloxetine.  

    – NaSSAs: Mirtazapine.  

    – Tianeptine (Stablon): Enhances serotonin reuptake (for cases of excess synaptic serotonin).  

– Adjunctive Treatments:  

  – Anxiolytics (e.g., benzodiazepines for short-term anxiety; avoid prolonged use to prevent dependence).  

  – Antipsychotics (e.g., Haloperidol, Risperidone, Olanzapine) for psychotic features.  

  – Mood stabilizers (e.g., Carbamazepine, Valproate) for relapse prevention.  

  – Others: Neuroprotectants (piracetam, citicoline, ginkgo biloba, vinpocetine, choline alfoscerate, cinnarizine), anxiolytics/sedatives (etifoxine, zopiclone, eszopiclone, hydroxyzine, beta-blockers), vitamins/minerals.

2.2. Electroconvulsive Therapy (ECT)  

– Preferred for severe depression with suicidal ideation/behavior, treatment-resistant cases, or failure of other therapies.  

– Strict adherence to contraindications to prevent complications.

2.3. Transcranial Magnetic Stimulation (TMS)  

– Preferred for mild to moderate depression.  

– Follow indications and contraindications to minimize risks.

2.4. Psychosocial Interventions  

– Cognitive-Behavioral Therapy (CBT).  

– Family therapy.  

– Individual therapy.  

– Relaxation/exercise therapy.  

– Mental health education.  

– Combine therapies for optimal outcomes.

3. Specific Treatments  

– Antidepressants: 1-3 agents:  

  – TCAs: Amitriptyline (25-200 mg/day), Clomipramine (50-100 mg/day).  

  – SSRIs: Sertraline (50-300 mg/day), Fluoxetine (20-60 mg/day), Fluvoxamine (50-100 mg/day), Citalopram (20-60 mg/day), Escitalopram (10-20 mg/day), Paroxetine (20-80 mg/day).  

  – SNRIs: Venlafaxine (37.5-225 mg/day), Duloxetine (40-120 mg/day).  

  – NaSSAs: Mirtazapine (15-60 mg/day).  

  – Dopamine-Norepinephrine Reuptake Inhibitors: Bupropion (75-450 mg/day).  

  – Other: Tianeptine (variable efficacy).  

– Antipsychotics: 1-3 agents:  

  – Haloperidol (5-30 mg/day), Chlorpromazine (25-500 mg/day), Levomepromazine (25-500 mg/day), Sulpiride (25-200 mg/day), Risperidone (1-10 mg/day), Olanzapine (5-30 mg/day), Quetiapine (50-800 mg/day), Clozapine (25-900 mg/day), Aripiprazole (5-30 mg/day).  

– Benzodiazepines: 1 agent:  

  – Diazepam (5-30 mg/day), Lorazepam (1-4 mg/day), Clonazepam (1-8 mg/day), Bromazepam (3-6 mg/day).

V. PROGNOSIS AND COMPLICATIONS  

– Most severe complication: Suicidal ideation or behavior.  

– Physical decline possible due to refusal to eat/drink.

VI. PREVENTION  

– No absolute prevention due to complex, intertwined causes.  

– Relative prevention: Educate children early to build resilient personalities, monitor those with family history for early detection/treatment, ensure sustained maintenance therapy to prevent relapse, and support psychosocial rehabilitation for community reintegration.

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